On the presidential campaign trail, Joe Biden promised to protect and build on the Affordable Care Act, a significant accomplishment of the Obama-Biden administration. During his presidency, Donald Trump subsequently weakened the ACA through executive orders that changed how individuals obtain coverage and care, as well as through support for legal challenges that sought to strike down the law. Despite these efforts, the ACA currently remains intact.
Once Biden takes office as president in January, he’ll likely move to reverse many of the actions Trump took to undermine the ACA. How much change Biden can effect is contingent on the outcomes of two ongoing contests: 1) the runoff elections in Georgia for two US Senate seats, and 2) California v. Texas, the latest challenge to the ACA in the Supreme Court.
Georgia’s runoff election, scheduled for January 5, 2021, has implications for the balance of power in the US Senate. Democratic victories would create a 50-50 split between Democrats and Republicans, with Vice President-elect Kamala Harris as the tiebreaker. The Supreme Court case could uphold or diminish the ACA’s legality; the court’s decision is expected in spring 2021.
Given these uncertainties, Biden’s more ambitious proposals, such as creating a public option for health insurance and lowering the Medicare eligibility age to 60, probably won’t become realities. Still, he will be able to reverse Trump’s executive orders.
“There were hundreds of Trump executive orders,” says Mark Pauly, a professor of healthcare management at the Wharton School of the University of Pennsylvania. “The most important are those that permitted alternatives to Obamacare insurance, like short-term plans going three years, and the orders or rules applying to Medicaid programs that were more permissive in terms of states being allowed to restrict access. Biden could reverse these on Day 1. They have to be sent for review, but proposals to revoke these things could be put in place immediately.”
Given Biden’s executive order powers, here are the most likely healthcare changes we’ll see during his first term:
Bye-bye “skinny” healthcare plans
Trump’s Health and Human Services, Labor and Treasury departments announced in summer 2018 that Americans could enroll in short-term, limited-duration insurance plans, also known as nonqualified short-term or “skinny” plans. These plans aren’t subject to the ACA’s essential health benefits requirement, meaning they don’t need to insure people with preexisting conditions or include coverage for services such as prescription drugs, mental healthcare and substance abuse treatment. These “just-in-case” plans were intended for transitional periods of up to three months, but the Trump administration extended that period to three years.
The impact: Reversing Trump’s expansion of skinny plans will force some people to purchase costlier health insurance plans, but it will also close the loophole allowing for cheaper insurance plans with minimal coverage. “Extending short-term plans is contrary to the idea of having comprehensive insurance,” says Gerald Kominski, a professor of health policy and management at the UCLA Center for Health Policy Research. “It was a way to whittle away at the edges, giving people the option to buy cheap plans if they’re healthy — gambling they’ll remain healthy for a couple of years and save a helluva lot of money. But since the ACA is still in effect, they can always give up the skinny policy and go back into the marketplace, and be guaranteed not to be charged more for their preexisting condition.”
Renewed ACA enrollment efforts
While in office, Trump cut funding to the ACA, specifically slashing budgets for promotion and assistance to consumers selecting plans. Trump officials also cut the open enrollment period on the federal exchange from 12 weeks to six weeks, and ignored requests from insurers and governors to open a special enrollment period to allow the uninsured to select policies during COVID.
The impact: Reversing Trump’s measures to curtail enrollment in health insurance plans through the federal marketplace will result in more uninsured people getting coverage. “Biden can increase the administrative budget for advertising and expand the enrollment period for ACA with executive orders,” says Robert J. Blendon, a professor of health policy and political analysis at Harvard University. “He can encourage and make it easier for individuals to sign up and enroll.”
Rollback of work requirements for Medicaid
Medicaid, a program jointly funded by the federal and state governments and overseen by states, provides health insurance to low-income and disabled individuals, as well as select health services to the elderly. In early 2018, the Centers for Medicare and Medicaid Services announced that states could require Medicaid recipients to either work or enroll in school or job-training programs for a certain number of hours each week to keep or apply for Medicaid coverage. In Arkansas, the only state to impose these work requirements, more than 18,000 people lost insurance coverage in 2018, according to the Arkansas Department of Human Services.
The impact: As Biden has promised to expand Medicaid, expect requirements and restrictions to roll back as the federal government offers states financial incentives to provide more people with coverage. “Biden will try to get states to expand Medicaid,” Pauly says. “States will take the government’s money and expand Medicaid to all low-income people.”
Planned Parenthood funding
In 2017, Trump signed a bill allowing states to withhold federal money from organizations that provide abortion services, including Planned Parenthood. And in 2019, the Trump administration implemented the “Protect Life” rule affecting health clinics receiving Title X federal funding. The rule restricts clinics from providing or even counseling patients about abortion services. The affected clinics typically serve about 4 million low-income people each year. Last summer, Planned Parenthood decided to withdraw from Title X rather than abide by the new requirements; about 900 clinics had dropped out of the program by the start of 2020.
The impact: The Biden administration is likely to reinstitute an Obama-era directive that states cannot bar Medicaid funds from going to qualified providers that separately provide abortions, such as Planned Parenthood. (Medicaid funding does not cover abortions, except in cases of rape or incest, or when the mother’s life is at risk.) Biden will likely also revoke the Trump administration rule barring federally funded health care providers in the Title X family planning program from referring patients for abortions. “Planned Parenthood provides prenatal and family planning services to millions of women all over the country,” Kominski says. “These were significant cuts. The funding will be restored pretty quickly under Biden.”
Restoration of individual mandate
In 2018, Congress voted to get rid of the individual mandate, which imposed a financial penalty on anyone who sidestepped the ACA requirement to obtain basic health insurance. The individual mandate was designed as a cost-control measure: It incentivized healthy people to buy into the insurance marketplace, thus lowering everyone’s premiums. A $0 penalty for not having health insurance went into effect in 2019. The penalty being reduced to nothing, combined with slashed HealthCare.gov sign-up advertising budgets, resulted in fewer insured Americans. The number of uninsured Americans increased by 2.3 million from 2016 to 2019, to 29.2 million (that’s 10.8 percent of the population), including 726,000 children, according to the US Census Bureau.
The impact: Biden doesn’t need to reimpose the individual mandate, as it never went away. “Congress didn’t repeal the individual mandate,” Kominski says. “They zeroed it out. That it’s zero today does not mean it’s eliminated — it’s been modified. It’s like changing the tax code. Another Congress could increase it, reinstituting it through budget conciliation.” While a Republican-led Senate may be unlikely to raise the individual mandate to a significant amount, a 50-50 Senate would make it more realistic.
Aggressive measures to combat COVID
Biden’s administration is tasked with addressing a global health emergency. Facing a nationwide surge in COVID infections and deaths, Biden will issue orders to contain the spread of the virus and improve the country’s chances of limiting its casualties. These orders will likely include a national mask mandate, efforts to secure and bolster the country’s personal protective equipment supply, rejoining the World Health Organization and coordinating plans for testing and vaccine distribution.
The impact: Trump repeatedly disagreed with his health officials on COVID and deferred to governors’ responses to the virus. Biden has pledged to “listen to science” in his approach to fighting COVID and to establish a pandemic testing board to coordinate a nationwide response.